Breast Cancer

What is Breast Cancer?

In breast cancer, cells in your breast begin growing abnormally often for unknown reasons. These cells divide more rapidly than healthy cells and may spread through your breast or into other parts of your body. The most common type of breast cancer begins in the ducts designed to carry milk after childbirth, but cancer may also occur in the small sacs that produce milk (lobules) or in other breast tissue.

Breast cancer is the disease many women fear most, though they’re far more likely to die of cardiovascular disease than they are of all forms of cancer combined. Still, breast cancer is second only to lung cancer as a cause of cancer deaths in American women. More than 200,000 American women are diagnosed annually with breast cancer. And nearly 40,000 American women die annually of breast cancer. Although rare, breast cancer can also occur in men.

Yet there’s more reason for optimism with regard to breast cancer than ever before. Great strides have been made in diagnosis and treatment in the last 25 years. In 1975 a diagnosis of breast cancer usually meant radical mastectomy  removal of the entire breast along with underarm lymph nodes and skin and muscles underneath the breast. Today, radical mastectomy is rarely performed. Instead, there are more and better treatment options, and many women are candidates for breast-sparing operations, such as lumpectomy.

Emphasis is also being placed on early detection, lifestyle changes and therapies such as tamoxifen that may reduce the risk of breast cancer. In addition, a growing network of agencies and resources exist to help those who have just received a diagnosis, are facing treatment decisions or are living with breast cancer.

What are the signs and symptoms of Breast Cancer?

Knowing the signs and symptoms of breast cancer may help save your life. When the disease is discovered early, you have more treatment options and a better chance for long-term recovery. In fact, when breast cancer is diagnosed and treated in its early stages, the five-year survival rate is 95 percent.

Most breast lumps aren’t cancerous. Yet the most common sign of breast cancer for both men and women is a lump or thickening in the breast. Often, the lump is painless. Other signs of breast cancer include:

• A spontaneous clear or bloody discharge from your nipple
• Retraction or indentation of your nipple
• A change in the size or contours of your breast
• Any flattening or indentation of the skin over your breast
• Redness or pitting of the skin over your breast, like the skin of an orange

A number of factors other than breast cancer can cause your breasts to change in size or feel. In addition to the natural changes that occur during pregnancy and your menstrual cycle, other common noncancerous (benign) breast conditions include:

• Fibrocystic changes. This condition can cause your breasts to feel ropey or granular. Fibrocystic changes are extremely common, occurring in at least half of all women. In most cases the changes are harmless. And they don’t mean you’re more likely to develop breast cancer. If your breasts are very lumpy, performing a breast self-exam is more challenging. Becoming familiar with what’s normal for you through self-exams will help make detecting any new lumps or changes easier.
• Cysts. These are fluid-filled sacs that frequently occur in the breasts of women ages 35 to 50. Cysts can range from very tiny to about the size of an egg. They can increase in size or become more tender just before your menstrual period, and may disappear completely after it. Cysts are less common in postmenopausal women.
• Fibroadenomas. These are solid, noncancerous tumors that often occur in women during their reproductive years. A fibroadenoma is a firm, smooth, rubbery lump with a well-defined shape. It will move under your skin when touched and is usually painless.
• Infections. Breast infections (mastitis) are common in women who are breast-feeding or who recently have stopped breast-feeding, although you can also develop mastitis that’s not related to breast-feeding. Your breast will likely be red, warm, tender and lumpy, and the lymph nodes under your arm may swell. You also feel slightly ill and have a low-grade fever.
• Trauma. Sometimes a blow to your breast or a bruise also can cause a lump. But this doesn’t mean you’re more likely to get breast cancer.
• Calcium deposits (microcalcifications). These tiny deposits of calcium can appear anywhere in your breast and often show up on a mammogram. Most women have one or more areas of microcalcifications of various sizes. They may be caused by secretions from cells, cellular debris, inflammation, trauma or prior radiation. They’re not the result of calcium supplements you take. The majority of calcium deposits are harmless, but a small percentage may be precancerous or cancer. If any appear suspicious, your doctor will likely recommend additional tests.

If you find a lump or other change in your breast and haven’t yet gone through menopause, you may want to wait through one menstrual cycle before seeing your doctor. If the change hasn’t gone away after a month, have it evaluated promptly.

Screening and diagnosing Breast Cancer

Screening – looking for evidence of disease before symptoms appear  is the key to finding breast cancer in its early, treatable stages. Depending on your age and risk factors, screening may include breast self-examination, examination by your nurse or doctor (clinical breast exam), mammograms (mammography) or other tests.

Breast self-examinationFor years, women have been advised to examine their breasts on a monthly basis starting around age 20. The hope was that by becoming proficient at breast self-examination and familiar with the usual appearance and feel of their breasts, women would be able to detect early signs of cancer.

But some studies have shown that teaching women to perform breast self-exams may not accomplish this goal. A large, randomized clinical study in Shanghai, China, for example, concluded that breast self-exams don’t actually reduce the number of deaths from breast cancer. In addition, the study found that women who perform regular breast self-exams may be more likely to undergo unnecessary biopsies after finding breast lumps. This was one of the primary reasons that in May 2003 the American Cancer Society changed its recommendations on breast self-examination, stating that the procedure should be considered an option, rather than a requirement, for most women.

The new guidelines emphasize breast health awareness instead of a strict series of monthly self-exams. Although the guidelines don’t say you shouldn’t perform the exams, the importance of self-exams has been replaced by a general need to become more familiar with your breasts. If you’d like to continue performing breast self-exams, ask your doctor to review your technique.

Clinical breast exam

Unless you have a family history of cancer or other factors that place you at high risk, the American Cancer Society recommends having clinical breast exams once every three years until age 40. After that, the American Cancer Society recommends having a yearly clinical exam.

During this exam, your doctor examines your breasts for lumps or other changes. He or she may be able to feel lumps you miss when you examine your own breasts and will also look for enlarged lymph nodes in your armpit (axilla).

Mammogram

A mammogram, which uses a series of X-rays to show images of your breast tissue, is currently the best imaging technique for detecting tumors before you or your doctor can feel them. For that reason, the American Cancer Society has long recommended screening mammography for all women over 40.

Yet mammograms aren’t perfect. About 10 percent to 15 percent of breast cancers sometimes even lumps you can feel  don’t show up on X-rays (false-negative result). The rate is higher about 25 percent  for women in their 40s. That’s because women of this age and younger tend to have denser breasts, making it more difficult to distinguish abnormal from normal tissue.

At other times, mammograms may indicate a problem when none exists (false-positive result). This can lead to unnecessary biopsies, fear and anxiety, as well as to increased health care costs. Even so, the consensus has been that if mammography saves lives, then all eligible women should be screened.

That assumption has been challenged in recent years especially by a 2001 analysis of several large, long-term studies that raised questions about the benefit of mammography screening for breast cancer. The report concluded that several prior studies didn’t clearly show that screening mammograms result in fewer deaths from breast cancer. This led to great confusion about mammography for both women and doctors.

But a study published in April 2003, in which researchers followed more than 200,000 Swedish women for 20 years, hopes to end the confusion. That study found that mammogram screening does indeed reduce breast cancer mortality for women between the ages of 40 and 69 by as much as 28 percent. What’s more, the study’s authors say that mammography screening along with improved treatments can halve the number of deaths from breast cancer.

In May 2003, the American Cancer Society issued updated guidelines on breast cancer screening, strongly reaffirming its recommendation that women 40 and older have annual mammograms. Additional American Cancer Society screening guidelines include the following:

• If you’re in your 20s or 30s, have a clinical breast exam every three years, and have one annually if you’re 40 or older.
• Know how your breasts normally feel and report any changes to your doctor. Starting in your 20s, breast self-examination is an option.
• If you’re at greater risk of breast cancer due to a family history, genetic makeup or past breast cancer, talk with your doctor. You may benefit from more frequent exams, earlier mammography or additional tests.

During a mammogram, your breasts are compressed between plastic plates while a radiology technician takes the X-rays. The whole procedure should take less than 30 minutes. You may find mammography somewhat uncomfortable. If you have too much discomfort, inform the technician. If you have tender breasts, schedule your mammogram for a time after your menstrual period. Avoiding caffeine for two days before the test also helps reduce breast tenderness.

Also available at some mammography centers is a soft, single-use, foam pad that can be placed on the surface of the compression plates of the mammography machine, making the test kinder and gentler. The pad doesn’t interfere with the image quality of the mammogram.

If possible try to schedule your mammogram around the same time as your annual clinical exam. That way the radiologist can specifically look at any changes your doctor may discover.

Most importantly, don’t let a lack of health insurance keep you from having regular mammograms. Many state health departments and Planned Parenthood clinics offer low-cost or free screenings. So does the Encore Plus program available through many YWCAs.

Other screening tests

• Computer-aided detection (CAD). In traditional mammography, your X-rays are reviewed by a radiologist, whose skill and experience play a large part in determining the accuracy of the test results. In CAD, a computer scans your mammogram after a radiologist has reviewed it. CAD identifies more suspicious areas on the mammogram, but many of these areas may later prove to be normal. Still, using mammography and CAD together may increase the cancer detection rate by nearly 20 percent.
• Digital mammography. In this procedure, an electronic process is used to collect and display X-ray images on a computer screen. This allows your radiologist to alter contrast and darkness, making it easier to identify subtle differences in tissue. In addition, the images can be transmitted electronically, so women who live in remote areas can have their mammograms read by an expert who is based elsewhere. Because it’s not yet known whether digital mammography is more accurate or effective than conventional mammography, the procedure is undergoing further investigation.
• Magnetic resonance imaging (MRI). This technique uses a magnet linked to a computer to take pictures of the interior of your breast. Although not used for routine screening, MRI can reveal tumors that are too small to be detected through physical examination or are difficult to see on conventional mammograms. It’s used at some centers to screen women at high risk of breast cancer as a complementary test to mammograms. MRI isn’t recommended for routine screening because it has a high rate of false-positive results, which can lead to unnecessary anxiety and biopsies.
• Ductal lavage. In this procedure, your doctor inserts a tiny, flexible tube (catheter) into the lining of a duct in your breast the site where most cancers originate and withdraws a sample of cells. The cells are then examined for precancerous changes that might eventually lead to disease. These changes show up long before tumors can be detected on a mammogram. But because ductal lavage is a new procedure, many unknowns remain, including the rate of false-negative results and whether abnormal cells will necessarily lead to cancer. Clinical trials are being conducted to help find the answers to these questions. In the meantime, some doctors are recommending ductal lavage to women who are at high risk of breast cancer either because they have a personal or family history of the disease or because they have a genetic defect that makes them more likely to develop cancer. Ductal lavage is still considered experimental, so many insurers don’t cover it. If you have an interest in or questions about the procedure, talk to your doctor.
• Breast ultrasound (ultrasonography). Your doctor may use this technique to evaluate an abnormality seen on a mammogram or found during a clinical exam. Ultrasound uses sound waves to form images of structures deep within the body. Because it doesn’t use X-rays, ultrasound is a safe diagnostic tool that can help determine whether an area of concern is a cyst or solid tissue. But breast ultrasound isn’t used for routine screening because it has a high rate of false-positive results finding problems where none exist.

Diagnostic procedures

If you, your doctor or a mammogram detects a lump in your breast, you’ll likely have one or more diagnostic procedures to determine if the lump is cancerous, including:

• Ultrasound 
  Often, your doctor will suggest a less invasive procedure, such as ultrasound, before deciding on a biopsy. Ultrasound is a procedure that uses sound waves to create an image of your breast on a computer screen. By analyzing this image, your doctor may be able to tell whether a lump is a cyst or a solid mass. Cysts, which are sacs of fluid, usually aren’t cancerous, although you may want to have a painful cyst drained with a needle.
• Biopsy
  In some cases, your doctor may want to remove a small sample of tissue (biopsy) for analysis in the laboratory. To do so, he or she may use one of the following procedures:
  • Fine-needle aspiration biopsy. The simplest type of biopsy, this is used for lumps you or your doctor can feel. During the procedure your doctor uses a thin, hollow needle to withdraw cells from the lump. He or she then sends the cells to a lab for analysis. The procedure isn’t uncomfortable, takes about 30 minutes and is similar to drawing blood. Another procedure, fine-needle aspiration, is used primarily to remove the fluid from a painful cyst, but it can also help distinguish a cyst from a solid mass.
  • Core needle biopsy. During this procedure, a radiologist or surgeon uses a hollow needle to remove tissue samples from a breast lump. As many as 15 samples, each about the size of a grain of rice, may be taken, and a pathologist then analyzes them for malignant cells. The advantage of a core needle biopsy is that it removes tissue, rather than just cells, for analysis. Sometimes your radiologist or surgeon may use ultrasound to help guide the placement of the needle.
  • Stereotactic biopsy. This technique is used to evaluate an area of concern that can be seen on a mammogram but that cannot be felt or seen on an ultrasound. During the procedure, a radiologist takes a core needle biopsy, using your mammogram as a guide. Stereotactic biopsy usually takes about an hour and is performed using local anesthesia.
  • Wire localization. Your doctor may recommend this technique when a worrisome lump is seen on a mammogram but can’t be felt or evaluated with a stereotactic biopsy. Using your mammogram as a guide, a thin wire is placed in your breast and the tip guided to the lump. Wire localization is usually performed right before a surgical biopsy, and is a way to guide the surgeon to the area to be removed and tested.
  • Surgical biopsy. This remains one of the most accurate methods for determining whether a breast change is cancerous. During this procedure, your surgeon removes all or part of a breast lump. In general, a small lump will be completely removed (excisional biopsy). If the lump is larger, only a sample will be taken (incisional biopsy). The biopsy is generally performed on an outpatient basis in a clinic or hospital.

Estrogen and progesterone receptor tests

If a biopsy reveals malignant cells, your doctor will recommend additional tests such as estrogen and progesterone receptors tests  on the malignant cells. These tests help determine whether female hormones affect the way the cancer grows. If the cancer cells have receptors for estrogen or progesterone or both, your doctor may recommend treatment with a drug such as tamoxifen that prevents estrogen from binding to these sites.

Staging tests

Staging tests help determine the size and location of your cancer, and whether it has spread. They also help your doctor determine the best treatment for you. Cancer is staged using the numbers 0 through IV.

Stage 0 cancers are also called noninvasive or in situ (in one place) cancers. Although they don’t have the ability to spread to other parts of your body or invade normal breast tissue, it’s important to have them removed because they eventually can become invasive cancers. Finding and treating a cancerous lump at this stage offers the best chance for a full recovery.

Stage I to IV cancers are invasive tumors that have the ability to spread to other areas. A stage I cancer is small and well localized, and has a very successful treatment rate. But the higher the stage number, the lower the chances of cure. By stage IV, the cancer has spread beyond your breast to other organs, such as your bones, lungs or liver. Although it may not be possible to eliminate the cancer at this stage, its spread may be controlled with radiation, chemotherapy or both.

Genetic testing

The discovery of BRCA1, BRCA2 and other genes that may significantly increase breast cancer risk has raised a number of emotional and legal questions about genetic testing. A simple blood test can help identify defective BRCA genes, but it’s only 85 percent accurate, and most experts believe that only those women at high risk of hereditary breast or ovarian cancers should be referred for testing. If you’re one of these women, it’s important to know that having a defective BRCA gene doesn’t mean you’ll get breast cancer. In addition, test results cannot determine how high your risk is, at what age you might develop cancer, how aggressively the cancer might progress or what your risk of death may be.

In general, testing is most beneficial if the results of the test will help you make a decision about how you might best reduce your chance of developing breast cancer. Options range from lifestyle changes, closer screening and therapy with medications such as tamoxifen to extreme measures such as preventive (prophylactic) bilateral mastectomy or removal of your ovaries (oophorectomy). These can be wrenching decisions for any woman to make. Be sure to thoroughly discuss all your options with a genetic counselor, who can explain the risks, benefits and limitations of genetic testing. It can also help to talk to other women who have had to make similar decisions.

How is Breast Cancer treated?

A diagnosis of breast cancer is one of the most difficult experiences you can face. In addition to coping with a life-threatening illness, you must make complex decisions about treatment. Remember, in most cases no one right treatment exists for breast cancer. Instead, you’ll want to find the approach that’s best for you.

To do that, you’ll need to consider many different factors, including the type and stage of your cancer, your age, risk factors, where you are in your life, the size and shape of your breasts, and your feelings about your body.

Before making any decisions, learn as much as you can about the many treatment options that exist. Talk extensively with your health care team. Consider a second opinion from a breast specialist in a breast center or clinic. Don’t be afraid to ask questions. In addition, look for breast cancer books, Web sites and information available from organizations such as the American Cancer Society and the Susan G. Komen Breast Cancer Foundation. Talking to other women who have faced the same decision also may help. This may be the most important decision you ever make.

Treatments exist for every type and stage of breast cancer. Most women will have surgery and an additional (adjuvant) therapy such as radiation, chemotherapy or hormone therapy. And several experimental treatments are now offered on a limited basis or are being studied in clinical trials.

Surgery

At one time, the only type of breast cancer surgery was radical mastectomy, which removed the entire breast, along with chest muscles beneath the breast and all the lymph nodes under the arm. Today, this operation is rarely performed. Instead, the majority of women are candidates for breast-saving operations, such as lumpectomy. Less radical mastectomies and mastectomy with reconstruction are also options.

Breast cancer operations include the following:

• Lumpectomy. This operation saves as much of your breast as possible by removing only the lump plus a surrounding area of normal tissue. Your surgeon will likely also do a sentinel lymph node dissection to check for possible spread of cancer. In most cases, your operation will be followed by radiation therapy to kill any remaining cancer cells. You usually have radiation therapy every weekday for six to seven weeks. Many women can have lumpectomy plus radiation instead of mastectomy, and in most cases survival rates for both operations are the same. In addition, many more women are satisfied with their appearance after lumpectomy. But lumpectomy may not be an option if a tumor is deep within your breast, or if you’ve already had radiation therapy, have two or more areas of cancer in the same breast that are far apart, have a connective tissue disease that makes you sensitive to radiation or are pregnant. Keep in mind that if you choose lumpectomy, you’ll often also need radiation.
• Partial or segmental mastectomy. Also considered a breast-sparing operation, partial mastectomy involves removing the tumor as well as some of the breast tissue around the tumor and the lining of the chest muscles that lie beneath it. Some lymph nodes under your arm also may be removed. In almost all cases, you’ll have a course of radiation therapy following your operation.
• Simple mastectomy. During a simple mastectomy, your surgeon removes all your breast tissue the lobules, ducts, fatty tissue and a strip of skin with the nipple and areola. Depending on the results of the operation and follow-up tests, you may also need further treatment with radiation, chemotherapy or hormone therapy.
• Modified radical mastectomy. In this procedure, a surgeon removes your entire breast and some underarm (axillary) lymph nodes, but leaves your chest muscles intact. This makes breast reconstruction less complicated. But serious arm swelling (lymphedema)  a common complication of mastectomy is more likely to occur in modified radical mastectomy than in simple mastectomy with sentinel node biopsy. Your lymph nodes will be tested to see if the cancer has spread. Depending on those results, you may need further treatment.
• Sentinel lymph node biopsy. Breast cancer first spreads to the lymph nodes under the arm. That’s why all women with invasive cancer need to have these nodes examined. If your surgeon doesn’t plan to do this, be sure you understand the reason why. Until recently, surgeons would remove as many lymph nodes as possible. But this greatly increased the risk of numbness, recurrent infections and lymphedema a serious swelling of the arm. That’s why a procedure has been developed that focuses on finding the sentinel nodes the first nodes to receive the drainage from breast tumors and therefore the first to develop cancer. If a sentinel node is removed, examined and found to be healthy, the chance of finding cancer in any of the remaining nodes is very small and no other nodes need to be removed. This spares many women the need for a more extensive operation and greatly decreases the risk of complications.

Reconstructive surgery

Most women who undergo mastectomy are able to choose whether to have breast reconstruction. This is a very personal decision, and there’s no right or wrong choice. You may find, however, that you have feelings you didn’t expect about your breasts. It’s important to understand these feelings before making any decision.

If you would like reconstruction but aren’t a candidate for the procedure, you’ll need to find a way to come to terms with your disappointment. It may be extremely helpful to talk to other women who have experienced the same situation.

If reconstruction is an option, your surgeon will refer you to a plastic surgeon. He or she can describe the procedures to you and show you photos of women who have had different types of reconstruction. Your options include reconstruction with a synthetic breast implant or reconstruction using your own tissue to rebuild your breast. These operations can be performed at the time of your mastectomy or at a later date.

• Reconstruction with implants. Using artificial materials to reconstruct your breast involves implanting a silicone shell filled either with silicone gel or salt water (saline). If you don’t have enough muscle and skin to cover an implant, your doctor may use a tissue expander. This is an empty implant shell that inflates as fluid is injected. It’s placed under your skin and muscle, and your doctor gradually fills it with fluid  usually over a period of several months. When your muscle and skin have stretched enough, the expander is removed and replaced with a permanent implant. Recovery may take several weeks. In general, an implant makes your breast firmer than a normal breast. Implants may cause pain, swelling, bruising, tenderness or infection. And they do age over time, requiring replacement. There is also a long-term possibility of rupture, deflation and shifting.
• Reconstruction with a tissue flap. Known as a transverse rectus abdominis myocutaneous (TRAM) flap, this surgery reconstructs your breast using tissue, including fat and muscle, from your abdomen. Sometimes your surgeon may also use tissue from your back or buttocks. Because the procedure is fairly complicated, recovery may take six to eight weeks. You may also need future adjustments to the breast. Complications include the risk of infection and tissue death. If you have little body fat, this type of reconstruction may not be an option for you. On the other hand, a breast reconstructed from your own tissue doesn’t seem to interfere with the detection of tumors. It’s also permanent, and has the look and feel of a normal breast.
• Deep interior epigastric perforator (DIEP) reconstruction. In this procedure, fat tissue from your abdomen is used to create a natural-looking breast. But because your abdominal muscles are left intact, you’re less likely to experience complications than you are with traditional breast reconstruction. You may also have less pain, and your healing time may be reduced.
• Reconstruction of your nipple and areola. After initial surgery with either tissue transfer or an implant, you may have further surgery to make a nipple and areola. Using tissue from elsewhere in your body, your surgeon first creates a small mound to resemble a nipple. He or she may then tattoo the skin around the nipple to create an areola. Your surgeon may also take a skin graft from elsewhere on your body, place it around the reconstructed nipple to slightly raise the skin and then tattoo the skin graft.

Radiation therapy

Radiation therapy uses high-energy X-rays to kill cancer cells and shrink tumors. If you choose lumpectomy, or if a biopsy has confirmed that there are cancer cells in more than four lymph nodes in your armpit, your oncologist will likely recommend radiation to your chest wall after your mastectomy. Although the thought of radiation can be disturbing, it may help to know that it’s a more accurate and less aggressive treatment than it once was.

Radiation is usually started three to four weeks after surgery. You’ll typically receive treatment five days a week for six to seven weeks. The treatments are painless and are similar to getting an X-ray. Each takes about 30 minutes. The effects are cumulative, however, and you may become tired toward the end of the series. Your breast may be pink, puffy and somewhat tender, as if it had been sunburned.

More serious, long-term complications are rare but can sometimes occur. These include rib fractures, lung inflammation, injury to the heart, nerve damage and a change in the appearance and consistency of breast tissue. In extremely rare cases, a new tumor may result from radiation therapy.

Chemotherapy

Chemotherapy uses drugs to destroy cancer cells. Your doctor may recommend chemotherapy following surgery to kill any cancer cells that may have spread outside your breast. Treatment often involves receiving two or more drugs in different combinations. These may be administered intravenously, in pill form or both. You may have between four and eight treatments spread over three to six months.

In some cases, your doctor may suggest preoperative chemotherapy taking chemotherapy drugs to shrink a breast tumor before surgery. This may make it possible for you to have a lumpectomy rather than a mastectomy to remove the cancer, with the same survival rate as if you were to have chemotherapy after breast surgery.

No matter when it’s administered, chemotherapy can feel like another illness. The side effects may include hair loss, nausea, vomiting and fatigue. These occur because chemotherapy affects healthy cells especially fast-growing cells in your digestive tract, hair and bone marrow as well as cancerous ones. Not everyone has side effects, however, and there are now better ways to control them if you do.

Many new drugs can help prevent or greatly reduce nausea. Relaxation techniques, including guided imagery, meditation and deep breathing also may help. In addition, exercise has been shown to be effective in reducing fatigue caused by chemotherapy.

Hormone therapy

Hormone therapy is most often used to treat women with advanced (metastatic) breast cancer or as an adjuvant treatment a therapy that seeks to prevent a recurrence of cancer for women diagnosed with early-stage estrogen-receptor-positive cancer. Estrogen-receptor-positive cancer means that estrogen or progesterone might encourage the growth of breast cancer cells in your body. Normally, estrogen and progesterone bind to certain sites in your breast and in other parts of your body. But during this treatment, a hormonal medication binds to these sites instead and prevents estrogen from reaching them. This may help destroy cancer cells that have spread or reduce the chances that your cancer will recur.

Medications that reduce the effect of estrogen in your body include:

• Tamoxifen (Nolvadex). This is a synthetic hormone belonging to a class of drugs known as selective estrogen receptor modulators (SERMs). It’s used as a treatment for metastatic breast cancer, as an adjuvant therapy, especially in women with breast cancer who have gone through menopause, and sometimes as a preventive agent in high-risk women. You take tamoxifen daily, in pill form, for up to five years. It may reduce the risk of recurrence of breast cancer and is less toxic than most anticancer drugs. But tamoxifen isn’t trouble free. Women taking tamoxifen may experience menopausal symptoms such as night sweats, hot flashes, vaginal itch or discharge, and diminished sexual interest. Less common but potentially life-threatening side effects also can occur. These include blood clots in your lungs (pulmonary embolism) and legs (deep vein thrombosis) and endometrial cancer. Older women and women who are black are at greater risk of these side effects than are younger women or those who are white. In addition, some studies have shown that side effects of systemic adjuvant therapies  chemotherapy and tamoxifen may be more long-term than originally thought.
• Aromatase inhibitors. This class of drugs inhibits the effect of estrogen by reducing its production in your adrenal glands. Aromatase inhibitors are currently approved only for the treatment of metastatic cancer, but early studies suggest that they may be more effective than is tamoxifen in preventing the recurrence of breast cancer. And one drug, anastrozole (Arimidex), may perform better than does tamoxifen as an adjuvant therapy. For now, though, many oncology experts believe tamoxifen should remain the adjuvant treatment of choice for women with hormone-receptor-positive breast cancer, based on the drug’s years of proven benefits.

Biological therapy

Sometimes called biological response modifier or immunotherapy, this treatment tries to stimulate your body’s immune system to fight cancer. Using substances produced by the body or similar substances made in a laboratory, biological therapy seeks to enhance your body’s natural defenses against specific diseases. Many of these therapies are experimental and available only in clinical trials. One medication, trastuzumab (Herceptin), is a monoclonal antibody  a substance produced in a laboratory by mixing cells that’s available for treating certain advanced cases of breast cancer. Herceptin is effective against tumors that produce excess amounts of a protein called HER-2, which occurs in about 25 percent of breast cancers.

Clinical trials

A number of new approaches to treating cancer are being studied. The emphasis is on methods that can successfully treat women or extend their survival with minimal side effects. Among these are drugs that block the biochemical switches that cause normal cells to turn cancerous. In addition, a procedure known as anti-angiogenesis which targets the blood vessels that supply nutrients to cancer cells is also being studied. And gene therapy is an area of ongoing research.

Of particular interest to both women and their doctors are methods of removing breast cancer without actually cutting into or removing the breast. Nonsurgical methods being studied include techniques that use heat or cold to kill cancer cells deep within the breast, leaving only minimal scars.

One of the most researched techniques, radiofrequency ablation, uses ultrasound to locate the tumor. Then a metal probe about the size of a toothpick is inserted into the tumor where it creates heat that destroys cancer cells. In early tests, the procedure has proved enormously successful. Still, only about 25 percent of women would be candidates for the procedure if it eventually were approved for widespread use.

Some of these new treatments are available through clinical trials the standard way new therapies are tested in people. If you have advanced breast cancer and are interested in participating in a clinical trial, talk to your doctor or contact the National Cancer Institute’s Information Service at 800-422-6237 for more information.